Community Pharmacists' Knowledge and Perception towards Telepharmacy Services and Willingness to Practice It in Light of COVID-19

Background During the COVID-19 pandemic, there was increased adoption of telepharmacy, which has proven benefits. This study was conducted to assess the knowledge and perception of the community pharmacists of Aseer region, Saudi Arabia, towards telepharmacy services and evaluate their willingness to adopt telepharmacy in clinical practice during the COVID-19 pandemic. Materials and Methods A cross-sectional study was conducted using an online self-administered structured anonymous questionnaire on the community pharmacists of Aseer region, Saudi Arabia. It covers demographics, computer access and literacy, knowledge and perception, and willingness to practice telepharmacy. Results were expressed as frequencies, percentages, and mean. The comparison between the classes of the demographic variables and the scores was done via Kruskal–Wallis and Mann–Whitney tests. Result About half of the pharmacists in our study showed average knowledge about telepharmacy, the practical application of telepharmacy technology, and telepharmacy guidelines with a percentage of 53%, 52%, and 47%, respectively). Majority of the participants showed high perception towards telepharmacy in Saudi Arabia, while 93% of the pharmacists in Saudi Arabia agreed that the implementation of telepharmacy technology is appropriate due to the current COVID-19 pandemic. Only a significant relation was found between gender and computer access, literacy, and perceptions towards telepharmacy with p values of 0.033 and 0.026, respectively. Conclusion The majority of the community pharmacists exhibited a positive perception and are willing to practice the concept of telepharmacy despite having a below average knowledge of telepharmacy. A future study involving the entire kingdom of Saudi Arabia could help identify the gaps in the knowledge, perception, and willingness to practice telepharmacy on a broader scale and thus promote telepharmacy adoption in the entire kingdom.


Introduction
Before the health crisis, virtual care services underwent a gradual upsurge to provide pharmaceutical care services to patients in remote areas with limited healthcare accessibility and facilities.However, due to the coronavirus disease 2019 (COVID-19) pandemic, there was increased adoption of telehealth, where patients communicate with the healthcare providers remotely for their healthcare needs and concerns by using technology [1][2][3].One area that comes under the umbrella of telehealth is telepharmacy, in which pharmacists provide patient care activities that improve the patients' safety and quality of life by reducing medication errors, adverse drug events, and reduced healthcare costs [2,4,5].Community pharmacists, who are a vital part of the healthcare system and are easily accessible, could play a prominent role in providing benefts to the community and improving the patients' health outcomes during the COVID-19 pandemic through this new concept of telepharmacy.Te National Association of Boards of Pharmacy described telepharmacy as "the provision of pharmaceutical care to patients at a distance through the use of telecommunication and information technologies" [6,7].In the past few years, telepharmacy has been practiced in various hospitals with proven benefts like enhancing patients' adherence towards medication use by providing sufcient medication counseling time with privacy, thus increasing patients' trust and satisfaction.For example, in a recent study conducted on remote hospital inpatients in Australia, Queensland, the concept of telepharmacy helped in providing medication-related advice and counseling [8].A study conducted on Canadian pharmacists reported that telepharmacy improved Canadian pharmacists' clinical practice, and they felt comfortable providing suggestions for mild ailments.Users' main reasons for using telepharmacy were that it was easier to set up the system, that privacy and data protection were better, and that the technology was easy to learn [9].Another study conducted in Spain on pharmacist teleconsultation of 38 patients reported a high level of patient satisfaction and achievement of treatment goals [10].A similar cross-sectional study conducted in Nigeria reported good acceptability of the concept by patients who were also willing to pay a moderately acceptable amount for the services [11].Along with proven benefts, several barriers have also been reported in the healthcare setting in the past.Some of them were lack of knowledge and training of employees, difculty in adopting new technology, expenses to implement, and patients' acceptance, which may afect the practice of telepharmacy.Pharmacists' knowledge and perception of telepharmacy determines the success and willingness to adopt telepharmacy in the pharmacy feld [12].So, it is essential to explore users' views about this novel technology.A recent study conducted in Riyadh city of Saudi Arabia assessed the knowledge and attitude of pharmacists towards telepharmacy; this study reported that the pharmacists exhibited poor knowledge but showed a positive attitude towards telepharmacy services and with adequate education and training, telepharmacy could be incorporated by the pharmacists into the healthcare system of Saudi Arabia [4].Another study conducted in Jordan reported that the community and hospital pharmacists showed a favorable attitude towards practicing this novel technology and emphasized the need to practice this telepharmacy technology as this COVID-19 may take time to resolve completely [13].Considering the pandemic situation where social distancing had become a norm and the rise in need for telepharmacy services to improve the quality of pharmaceutical services, this study aimed to assess the knowledge and perception of the community pharmacists of Aseer region, Saudi Arabia, towards telepharmacy services and evaluate their willingness to adopt telepharmacy in clinical practice during the COVID-19 pandemic.

Study Design and Setting.
A three-month cross-sectional study was conducted using an online self-administered structured anonymous questionnaire on the community pharmacists of Aseer region, Saudi Arabia.

Study Population, Sample Size, and Sampling Criteria.
Tis study targeted the community pharmacists of Aseer region, Saudi Arabia.Tere are a total of 747 licensed community pharmacists across 438 licensed community pharmacies [14].Te estimated minimum recommended sample size was 254 calculated by Raosoft, sample size calculator, with 95% confdence interval and 5% precision limit.Te inclusion criteria were practicing licensed Saudi and non-Saudi community pharmacists of both genders of Aseer region, Saudi Arabia.Te exclusion criteria were pharmacists from other sectors such as academics, hospitals, industries, pharmaceutical companies, and those not willing to participate.Tis study used snowball sampling to recruit eligible participants.Initially, we sent the survey link to some community pharmacists, and they forwarded the survey link to the other pharmacists.

Survey Instrument and Data
Collection.An online selfadministered structured anonymous questionnaire based on instruments used in a previous study of Albarrak et al. [7] was adapted by conducting an extensive literature review.Focus group discussions were held by conducting an informal online discussion with participants to understand their perceptions, beliefs, and information needs regarding this new technology service.Suggestions were taken, and a draft questionnaire was prepared to fulfll the objective of this study.It was then subjected to face and content validation where an informal review of a questionnaire by nonexperts was used to assess its clarity, comprehensibility, and appropriateness for the target group, as well as a formal assessment by subject experts to determine the appropriateness of the content and identify any misunderstandings or omissions.Te questionnaire was translated into Arabic for the participants' convenience and to avoid ambiguity.Even though the target population was community pharmacists, who are typically able to understand English, the questionnaire was translated into Arabic for the convenience of the participants and to eliminate any confusion they might encounter, as this was a self-administered questionnaire in which they will read, understand, and respond to the questions on their own.Te accuracy in translation was checked by researchers who were profcient in the native language and a pilot study was conducted.Te questionnaire was piloted with ten respondents representing the study population to determine the clarity of the language and the structure of the questionnaire.Te pilot study results were not included in the results; nevertheless, the feedback was analyzed, the double-barreled, confusing, and leading questions were modifed, and a fnalized questionnaire was created.

2
International Journal of Clinical Practice Te questionnaire consists of fve sections comprising 4 questions on demographic characteristics and general information such as age, gender, nationality, and work experience, 6 questions on general information about access to computers and their literacy, 5 questions each on knowledge and perception, and 3 questions assessing the willingness to practice telepharmacy.Te internal consistency of the knowledge, perception, and willingness to practice sections were assessed with Cronbach's alpha value each of 0.834, 0.792, and 0.677, respectively, indicating that the questions were reliable.Te scoring for the section on general information about access to computers and their literacy was measured as always or often � 2, sometimes or rarely � 1, and never � 0. A 3-point Likert scale was used to assess the pharmacist's knowledge (low � 0, average � 1, and high � 2), whereas a 2-point scale was used to measure perception and willingness; agree � 1 and disagree � 0. Te overall knowledge, perception, and willingness to practice were measured by the original Bloom's cutof points, 80.0-100.0%,60.0-79.0%,and ≤59.0%, which were adapted and modifed from the 2020 study by Khaled et al. [15].

Statistical Analysis.
After data collection, responses were downloaded in MS Excel fle and assessed blindly.Results were expressed as frequencies, percentages, and mean (descriptive statistics).Te comparison between the classes of the demographic variables and the scores was done via nonparametric tests named Kruskal-Wallis (age and work experience) and Mann-Whitney (gender) (SPSS Inc, Chicago, IL, USA).A p value <0.05 was considered signifcant.

Ethical Considerations. Te Research Ethics Committee
of King Khalid University approved this project, with approval number ECM# 2021-5627.Te consent of participants was requested and recorded on the very frst page of the survey, demonstrating their voluntary participation.

Results
Te study received 241 responses (response rate: 94.8%) of which some responses were incomplete, so excluding them from the analysis, the new total response was 228.Te demographics of the participants are presented in Table 1.Majority of the participants were female and most of them were reported to have less than 5 years of work experience as community pharmacists and were from the age group of 21-40 years.

Pharmacists' Computer Access and Literacy.
To adopt telepharmacy into practice, computer access and literacy are a necessity.Table 2 displays the responses related to the pharmacists' computer access and literacy.63% of the participants always use PC/laptop at home.Meanwhile, 32% often interact with patients via e-mail or through social media, 43% of them always use social media Internet for obtaining information to give to patients, only 39% use social media Internet for patient consultation, and 71% use social media Internet to update their knowledge and skills.

Pharmacists' Knowledge on Telepharmacy.
About half of the pharmacists in our study showed average knowledge about telepharmacy, the practical application of telepharmacy technology, and telepharmacy guidelines with a percentage of 53%, 52%, and 47%, respectively.Meanwhile, 45% showed that average response towards the impact of the continuous training in the use of telepharmacy is necessary for pharmacists and 43% had conferences, speeches, or meetings held in their workplace regarding telepharmacy technology.Te responses of pharmacists regarding their knowledge of telepharmacy are presented in Table 3.

Pharmacists Perception of Telepharmacy.
Majority of the participants showed high perception towards telepharmacy in Saudi Arabia.About 94% agreed that use of International Journal of Clinical Practice telepharmacy system during the COVID-19 pandemic can help patients.91% of the pharmacists believed that there is a potential role for ICT in the healthcare.89% of the participants agreed that telepharmacy is a viable approach for providing pharmaceutical care services to patients.86% of the participants believed in the time-saving efect of telepharmacy (Table 4).

Willingness to Practice
Telepharmacy.93% of the pharmacists in Saudi Arabia agreed that the implementation of telepharmacy technology is appropriate due to the COVID-pandemic.91% of the participants would like to consult with the large centers in their specialty, whilst they are in their own pharmacies.86% of the respondents agreed that the telepharmacy system can be integrated within the existing system (Table 5).

Regarding the Issues Afecting the Adoption of
Telepharmacy.Te participants were asked about the issues that may afect the adoption of telepharmacy, and their responses are listed in Table 6.86 community pharmacists showed concern about patient privacy and confdentiality, and 30% were worried about the availability of user-friendly software.Also, 27% showed concerns about the lack of consultation between information technology experts and clinicians, while 25% of them were worried about the perceived increase in workload.
Association between the demographic factors of the respondents and the computer literacy, knowledge, perception, and willingness using the Kruskal-Wallis/Mann-Whitney test showed that no signifcant association was noted between the participants with diferent age, diferent   7).Table 8 refects the mean score results of computer access and literacy, knowledge, attitude, and willingness to practice telepharmacy.Using Blooms cutof points, it was obvious that the participants displayed a positive perception towards the adoption of telepharmacy, and they were willing to practice telepharmacy despite having a below-average score of knowledge.

Discussion
Te impact of the COVID-19 outbreak on direct access to pharmaceutical services has boosted global interest in telepharmacy.Te purpose of this study was to investigate community pharmacists' knowledge, perception, and willingness to practice telepharmacy.According to the fndings, the study participants had below-average knowledge, which difers from the study in Riyadh by Alanazi et al. [16].Te introduction of COVID-19, according to Unni et al., has accelerated the necessary modifcations to make telepharmacy an appealing option.Tey also claimed that as healthcare practitioners and the general public become more aware of the benefts of telepharmacy, it may persist long after the pandemic [17].According to Ibrahim et al., pharmacies that use these tele services may be able to serve COVID-19 patients more quickly than pharmacies that do not use them [18].In response to the COVID-19 pandemic in a city of Vietnam, Dat et al. reported that 87% of the pharmacists used telepharmacy in their pharmacy practice.Tey also claimed that giving medical information and remote medicine guidance had become a compulsion in the context of the COVID-19 outbreak [19].Even though the pharmacists might not have enough knowledge about telepharmacy now, but due to this need to practice and continuous exposure, they might be forced to increase their knowledge on telepharmacy.
Whereas regarding their perception, the current study discovered that community pharmacists had a favorable perception towards telepharmacy adoption, which is similar to a study conducted on Jordanian pharmacists by Mufih et al., 2021 [13].According to 89% of the participants, telepharmacy is a realistic strategy for providing pharmaceutical care services to patients.Telepharmacy allows patients to avoid waiting at a clinic with other sick patients, save time traveling, avoid work loss, and get themselves and their family healthy when possible.According to 86% of the pharmacists in the current study, telepharmacy saves patients money and time by eliminating the need for them to visit healthcare facilities.Previous research has shown that telepharmacy reduces travel costs and saves time, which is a signifcant barrier for patients receiving healthcare in rural and remote settings, particularly the disabled and elderly [20].In Alanazi et al.'s study, more than 91% of the pharmacists believed that using a telepharmacy system would save them time and money [16].Telepharmacy and telehealth clinical pharmacy services help bridge the gap in rural locations where pharmacists and physicians are in short supply.In contrast to the study conducted by Liu et al. in China, this study indicated that the study participants were willing to provide remote services to their patients [21].Participants in a study done by Ahmed et al. were shown to be less prepared for telepharmacy [22].According to Elnaem et al., around 67% of the senior pharmacy students at a Malaysian public pharmacy school displayed excellent knowledge and   International Journal of Clinical Practice 68% demonstrated high readiness.Tey also discovered that characteristics, including a lack of enthusiasm and an extreme workload, were related to participants' telepharmacy preparedness [23].Payment and reimbursement concerns, as well as a lack of access to information technology infrastructure, were among the most signifcant hurdles, according to Ameri et al. [24].Dat et al. found that roughly 87.2% of the pharmacists in their survey were willing to employ telepharmacy [19].Pharmacy schools should incorporate telepharmacy practice models into their curricula to better train future pharmacists to provide telepharmacy services.Furthermore, pharmacists' expertise and preparedness to use telepharmacy can be strengthened through presenting lectures, workshops, and attending conferences.Continuing professional education and intense training may aid in increasing knowledge, which may improve community pharmacists' perception and willingness to practice.Te availability of appropriate and efcient resources, as well as the supply of incentives to pharmacists, would aid in the promotion of telepharmacy implementation [22].

Study Limitations.
Tis study has included participants from only the Aseer region, so the results cannot be generalized to all the community pharmacists of Saudi Arabia, but this can be overcome by expanding this study to the entire kingdom in the future.Te participants were recruited by snowball sampling to reach the community pharmacists working in the remote areas of the Aseer region; however, there might be a possibility of sampling bias.

Conclusion
Tis study concludes that the majority of the community pharmacists exhibited a positive perception and are willing to practice the concept of telepharmacy despite having a below average knowledge of telepharmacy.As telepharmacy holds signifcant promise and community pharmacists are the most frequently and easily approachable healthcare professionals, they should be encouraged to implement such technologies and be well trained by identifying the gaps.A future study involving the community pharmacists of the entire kingdom of Saudi Arabia could help identify the gaps in the knowledge, perception, and willingness to practice telepharmacy on a broader scale and thus promote telepharmacy adoption in the entire kingdom as there is an immense need for such remote service due to its convenience in providing remote healthcare services to patients, especially during the COVID-19 pandemic or any other epidemics that may arise in the future.

Table 2 :
Computer access and literacy.

Table 3 :
Knowledge of telepharmacy.
4 � No. of participants', % � percentage of participants.4InternationalJournal of Clinical Practice nationality, or diferent years of experience; there is only a signifcant relation between gender and computer access, literacy, and perceptions towards telepharmacy with p values of 0.033 and 0.026, respectively (Table

Table 5 :
Willingness to practice telepharmacy.

Table 6 :
Issues afecting the adoption of telepharmacy.

Table 7 :
Association between demographic characteristics and the computer access and literacy, knowledge, perception, and willingness to practice telepharmacy.

Table 8 :
Mean score results.